Art & science
If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Alleviating stress in the workplace: advice for nurses Wright K (2014) Alleviating stress in the workplace: advice for nurses. Nursing Standard. 28, 20, 37-42. Date of submission: October 2 2013; date of acceptance: October 18 2013.
Abstract Stress is an inherent and arguably essential aspect of the nurse’s role, with ongoing challenges associated with providing care for patients and their families. However, the level of stress currently being experienced in health care exceeds the capacity of many nurses, resulting in ill health and burnout. This stress can undermine the care and compassion nurses are able to give, a vital concern in health care which was highlighted by the Francis inquiry. This article explores the factors that contribute to stress and the strategies that can be used to alleviate the stresses inherent in nursing.
Author Kerri Wright Honorary staff counsellor, Occupational Health and Well being, Kingston Hospital NHS Foundation Trust, Surrey. Correspondence to: [email protected]
Keywords Burnout, compassion, counselling, leadership and management, self-care, stress
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
NURSING IS A stressful job. Excess and prolonged stress can lead to distress, burnout or physical illness for the individual (Marine et al 2009). For the organisation, stress can result in staff absence, increased staff turnover and increased costs, all of which can contribute to further stress for staff (Marine et al 2009, Francis 2013). The Health and Safety Executive (HSE) (2013a), through the Management of Health and Safety at Work Regulations 1999, identified stress as a health and safety issue and requires all organisations, including the NHS, to undertake stress risk assessments for staff to identify and prevent stress-related ill health. Increased stress has been linked to a reduction in compassion and caring in health care (Firth-Cozens and Cornwell 2009) and has become a major concern following the Francis (2013) inquiry. Nurses are more likely than other healthcare professionals to experience ill health because of stress, with 2,730 cases of sick leave because of work-related stress in 2011/12 per 100,000 nurses (HSE 2013b). Workers in the UK experiencing work-related stress in 2011/12, took 24 days off work on average (HSE 2013b). In a survey of 10,000 nurses by the Royal College of Nursing (RCN), 62% of nurses questioned reported that they had considered leaving the profession because of stress (The Press Association 2013).
Defining stress Stress is a response to perceived threat activated by the sympathetic nervous system (Wright et al 2011). The purpose of stress is to prepare the body for physical action. Therefore, heart rate increases, and blood flow increases to core organs and muscles, and decreases to peripheral or
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Art & science occupational health non-essential areas, for example the gut. This results in increased blood pressure, rapid and shallow breathing, and tension in the muscles; the body is in ‘fight or flight’ mode, ready for the danger sensed (Marieb 2010). Many chemicals are also released into the bloodstream as part of the stress response, in particular adrenaline (epinephrine) and corticosteroids (Rothschild 2006), to help prepare the body for action. When the body is required to act and respond to the threat as it has been designed to do, for example dealing with a clinical emergency or implementing care at a fast pace, the chemicals are discharged from the body, tension in the muscles relaxes, and heart rate and blood pressure return slowly to normal levels. Adverse effects on health occur when action cannot be taken to fight or flee the perceived threat and/or the threat is prolonged and enduring (Wicks 2010) (Box 1).
BOX 1 Levels of health problem that can occur when stress is prolonged or cannot be avoided Level 1 Signs and symptoms are relatively mild, short in duration and occur occasionally: Feeling mentally fatigued at the end of the day. Feeling unappreciated, frustrated, bored, tense or angry as a result of contact(s) with family, colleagues, supervisors, superiors, assistants or others. Experiencing physical symptoms, for example headache, backache and upset stomach. Pace of daily activities or requirements of present tasks seem greater than personal or professional resources available. Tasks required on the job are repetitive, beyond ability or require intensity on a continuous basis. Level 2 Signs and symptoms have become more persistent, last longer and are more difficult to eliminate: Idealism and enthusiasm about one’s occupation or profession is waning; disillusionment about work arises on a regular basis. Experiencing a general loss of interest in self for a period of one month or longer. Pervasive feelings of boredom, stagnation, apathy and frustration. Being ruled by schedule; not attuned to people or patients and colleagues, and viewing them impersonally and without consideration. Losing criteria with which to judge the effectiveness of work. Inability to be refreshed by other elements in one’s life, such as reading a book. A loss of interest in professional developments – new evidence, ideas and innovations for health care, for example. Intermittent but lengthy periods (lasting one week or more) of irritation, depression and stress that do not seem to be relieved even with effort to correct apparent causes. Level 3 Signs and symptoms have become chronic and a physical illness has developed, for example hypertension, colitis, depression and/or anxiety. (Wicks 2010)
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Stress occurs when perceived demands or pressures exceed current resources and potentially threaten wellbeing (Lazarus and Folkman 1984, HSE 2013c). In health care, there are challenges that could be perceived as threatening the wellbeing of nurses. For example, reduced services, focus on performance targets, staff shortages and increases in individual workloads contribute to the challenges nurses experience regularly (Francis 2013). The response to and perception of these challenges in health care are different for each nurse. The body responds to what is individually perceived to be threatening wellbeing. This involves beliefs, thoughts and feelings about the situation. The situation in reality, may not seem threatening to the individual or to those observing from the outside, nor will the situation affect everyone in the same way. To understand how these challenging situations come to be perceived as threatening to the wellbeing of individual nurses, it is important to consider the demands of the work environment as causes of stress, the individual and how he or she is coping, as well as the complex interplay between the individual and his or her work environment and how this contributes to stress.
Factors causing stress Stress is caused when the demands placed on an individual exceed the resources he or she has at that time (Cox et al 2002, HSE 2013c). The demands on nurses derive not only from work, but include responsibilities and challenges in their personal lives (Jennings 2008). Although nurses are often told to leave their personal lives at home, the reality is that personal lives and sometimes family commitments affect work, for example an ill relative or childcare difficulties. Similarly, a person’s resources can become drained by demands and pressures at work and at home or a combination of both. A personal crisis can damage resources, resulting in reduced reserves for work. In the same way, work can drain resources, resulting in reduced reserves for managing personal lives. In addition, an individual’s resources will affect the number and type of demands that can be managed. This involves personal experiences and strategies for dealing with situations as well as feelings at a particular moment. At times of tiredness or distress, resources will be reduced. At other times, when the individual is refreshed and feeling confident, resources are greater. Resources are thus individual and can fluctuate. It is important, therefore, to consider all elements of a nurse’s life when assessing the demands on his or her resources and how these can be maximised to alleviate stress.
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When stress occurs in several areas, then it is likely that stress will be greater. Figure 1 illustrates that stress not only occurs in the overlapping areas of individual, personal life and work environment, but that each area can have an effect on available resources and whether resources can meet demand. To alleviate stress, nurses and managers need to consider how the demands placed on nurses can be reduced and how the resources to manage these demands can be increased. This requires nurses to consider the demands of personal lives, work and personal pressure, for example perfectionism or the need to feel valued. Nurses need to consider how resources can be increased from individual, personal and work perspectives. One of the recurring themes from research on the causes of stress experienced by healthcare professionals is whether nurses feel empowered in their work. Feeling disempowered appears to increase the perception of stress (Jennings 2008) and when nurses are given more autonomy they tend to feel less stressed. A study by the RCN and Unison commissioned by the HSE found that stress was not only experienced when the demands on nurses exceeded their resources, but was determined by the nurse’s perception of the demands and whether he or she felt able to cope (Cox et al 2002). Therefore, stress can be alleviated by reducing the demands or by increasing resources to cope with the demands, and by considering nurses’ beliefs about the situation and increasing the perceived control they have over what is happening to them.
Managing stress Stress can be alleviated by addressing the individual, work and personal life elements of a nurse’s life that contribute to stress, and examining how these elements interact and contribute to stress.
Individual element of stress
An individual’s ability to manage the demands placed on him or herself increases if he or she feels they have sufficient resources to meet these demands. For nurses, these resources include physical, emotional and mental capacity alongside clinical knowledge and skills. There is a complex interplay between these areas so that a reduction in one, for example feeling distressed, can impair the nurse’s ability to think clearly, make him or her feel physically drained and tired, and can affect his or her clinical performance. Similarly, if a nurse does not feel competent clinically and cannot meet the demands placed on him or her, the nurse can feel worthless, which can contribute to a pattern of negative thinking. Therefore, alleviating and managing stress requires the nurse to consider
FIGURE 1 Three interacting elements of stress
Individual
Work environment
Personal life
how situations at work make him or her feel, his or her thoughts about the situation and his or her behaviour, as well as paying attention to his or her physical health (Figure 2). Exploring these areas and taking steps to increase physical health or challenge thoughts about a situation, increases resources as a nurse will feel more in control of what is happening and more able to cope. The situation may not necessarily change, but the way the nurse thinks about it can, for example the nurse may be clearer about why the situation is causing him or her so much concern, what he or she can do to improve the situation, and what he or she may need to accept. Stress is exacerbated by feelings of being trapped and having no control over the situation (Jennings 2008, Wicks 2010). Part of alleviating stress is challenging this and gaining some control over the situation. Advice for managing stress is provided in Box 2. Counselling can be useful to help individuals become more aware of habitual patterns of thinking and to learn different strategies and techniques to help manage thoughts and feelings in situations (Marine et al 2009).
Work environment element of stress
The work environment and the structures in place to support staff are important in alleviating stress (Cox et al 2002, Jennings 2008, Firth-Cozens and Cornwell 2009). Challenges associated with providing complex care with decreasing resources are common in health care today. Healthcare settings can be under-staffed or can have high
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Art & science occupational health staff turnover, which has a negative effect on the experience and expertise available for patient care in the clinical area (Marine et al 2009, Francis 2013). The increase in work-related pressures inevitably leads to stress or other ill health causing sickness and absences, which leads to further understaffing and stress for the remaining staff. Healthcare work is demanding and workplaces need to look at how individuals can be given the resources to manage better these demands and what the workplace can do to minimise the demands being placed on nurses. The HSE (2013d) defined six management standards relating to the work environment that are the primary sources of stress at work and which need to be considered in any assessment of stress in the workplace. These standards are listed in Box 3.
FIGURE 2
v
Cycle of negative thinking Situation You cannot complete your workload
Thoughts I’m not doing a good job; I can’t do this job; I’m not good enough
Physical effects Tiredness, headaches, dizziness, poor concentration
Feelings On edge, scared, irritable, despairing, tearful
Behaviour Come into work early and stay late, take work home
BOX 2 Advice on managing stress Get enough sleep. Eat regular and nourishing meals and snacks. Incorporate exercise into the weekly routine. Take regular breaks at work. Make time to relax away from work. Problem solve and take action. Consider accepting that which cannot be controlled. Appreciate the individual and what the individual is doing. Focus on what gives meaning in work. Separate the personal from work and have interests and roles outside work that give life meaning.
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One of the main factors that alleviates stress in health care is the quality of leadership and management support given to staff (Firth-Cozens and Cornwell 2009, Francis 2013). Good management can ensure that structures are in place to support staff and that staff have the resources they need to perform their role (Jennings 2008). The study by the RCN and Unison identified eight areas of good practice that can help to alleviate stress in the workplace (Cox et al 2002) (Box 4). The examples of good practice help staff to focus on reducing demands, and resourcing and supporting staff and teams to better manage these demands. This involves managers having a genuine understanding of the work situation or a desire to hear and act on feedback from staff. This does not mean solely reducing the workload, but offering support, checking back with staff periodically and listening to the difficulties nurses are having at that time.
Personal life element of stress
Nurses should not let their personal lives affect their work, but the reality is that one’s personal life does affect work. When nurses are energised and confident, work will benefit. Similarly, when personal issues are causing distress and affecting sleep, for example, energy and resources available for work are limited. When nurses are stressed in their personal lives, they are more at risk of stress and ill health at work. It is important to accept that personal life will affect work and that a nurse may gain support during a personal crisis by informing his or her manager, consulting occupational health services and exploring psychological support through counselling.
BOX 3 Management standards for work-related stress Demands – this includes issues such as workload, work patterns and the work environment. Control – how much influence the person has in the way he or she works. Support – this includes encouragement, sponsorship and resources provided by the organisation, line management and colleagues. Relationships – this includes promoting positive working to avoid conflict and dealing with unacceptable behaviour. Role – whether people understand their role in the organisation and whether the organisation ensures that they do not have conflicting roles. Change – how change (large or small) is managed and communicated in the organisation. (Health and Safety Executive 2013d)
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For many, working life involves multiple roles and trying to manage these to ensure that expectations are met. It is important that managers appreciate the competing and conflicting roles that nurses have. Stress can be alleviated by allowing dialogue about work times and shift patterns where possible. For example, managers need to weigh up the benefit of reducing stress by allowing a nurse to finish half an hour earlier to take his or her child to a doctor’s appointment against the distress caused by denying this and affirming that the times when the nurse stayed late and worked hard have not been recognised. In addition, nurses have a responsibility to look after their health as best they can. This means managing personal commitments and balancing these with work demands. Maintaining a good work-life balance may require the nurse and his or her manager to negotiate this together.
Warning signs Nurses are accustomed to working under pressure and experience stress as an everyday feature of their work. Unless this stress is relieved in some way (Box 5), the effects on the body of being on high alert for long periods can have long-term consequences for health such as hypertension or depression. It is important, therefore, to integrate time into the daily schedule to de-stress. Stress is the body’s response to a perceived threat and prepares the body for action, physically and cognitively. The body is, therefore, ‘wound-up’, ready for physical action, and thoughts are alert and focused on the perceived stressor. Stress can be relieved via physical activity or talking through the events of the day (debriefing) to make sense of them. It is also important to consider relaxation techniques such as mindfulness practice, meditation, yoga or tai chi (Marine et al 2009). If the body and mind are not given an opportunity to discharge the energy, this will stay in the body and make it difficult for the individual to relax physically and mentally. Over a long period, this stress can start to have physical effects, causing hypertension or ulcers, and psychological effects, such as anxiety or depression. The long-term effects of stress can be invisible until quite a late stage, unless steps are taken to be more aware of responses to situations and to acknowledge that the shift or situation was stressful. Once an individual becomes physically and/or psychologically unwell through stress, it can take a long time to recover. Nurses should be taught – whether during pre-registration training, or later by occupational health staff or their manager – to recognise the early warning signs and take steps
BOX 4 Eight areas of good practice that can help to alleviate stress in the workplace 1. I ntroduce a forum for community information and to discuss and solve problems, for example team meetings or problem-solving workshops. 2. Make opportunities available for staff to design work that is interesting and stimulating, and allow staff a degree of control over how they do their work. If work is not interesting, managers should ensure job rotation so that staff experience some variety. 3. Ensure continuity of care so that staff can take responsibility for the care they provide and can see improvements in their patients. Direct care staff are known to derive satisfaction from seeing their work making a difference to people. 4. Use in-house training and systems to consolidate and disseminate expertise. Services should use the knowledge and expertise of their staff as a resource for training others, for example regular training sessions or specific roles such as nurse practitioners. 5. Help staff to develop by undertaking effective performance appraisal. 6. Be flexible about working hours where appropriate, for example reasonable request systems could be put in place to help manage the effect of work on home and social life. Open dialogue between those organising working hours and staff is crucial for these systems to work. 7. Promote cohesive and well managed teams. Management practices that actively discourage isolated working enhance the team environment. Working relationships are important to staff, and continuity of staffing is important for staff wellbeing. 8. Manage the work environment effectively, for example ensure that equipment is up to date and well maintained, and systems are in place to ensure condition and availability are monitored. (Cox et al 2002)
BOX 5 Ideas for relieving stress Mind: Introduce a debrief time with colleagues at the end of work where successes and frustrations of the day can be shared. Write a brief reflective journal after each shift with a focus on what went well, what could be improved and what could be done next time. Plan what needs to be done and write it in the journal. Create an escape from thoughts about work, for example watch television, read a book or have coffee with friends. Practise mindfulness through yoga or meditation to help focus on the present and control thinking around work. Have a period of protected ‘me time’ each day. This can be quietly listening to some music, sitting with a cup of tea and doing a puzzle or taking a warm bath. Find a time that fits into the routine and becomes a regular period for the mind to disengage from work. Body: Do some form of physical exercise regularly. The more vigorous the better, so that frustrations can be worked off during the activity. Punch some pillows or use a stick or baseball bat to hit them with. Find somewhere secluded and scream. Put music on full volume and sing or dance along as loudly and energetically as possible. Complete something tangible at home to give a sense of achievement, for example bake a cake, cook a meal, clean the bathroom or vacuum the floor. The physical exertion, and the focus on the task and the end product will help to channel frustrations and relieve stress.
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Art & science occupational health to prevent further deterioration in health. Once a person becomes aware of how the body and mind react to work-related stress, then he or she may be more motivated to take steps to look after him or herself and relieve the stress every day. Nurses should include activities that enable the body to relieve some of the stress in their daily routine.
Conclusion Stress is a normal and vital part of a nurse’s working life. Prolonged stress or work in situations where nurses feel trapped can cause levels of stress that can have a long-lasting effect on health. Stress is caused by an imbalance between the demands placed on an individual and the resources he or
she has available to cope with these demands. The demands and resources available to cope are affected by the individual’s skills, thoughts and beliefs about him or herself and work, the work environment, support structures available, and his or her personal life. Stress affects people in different ways and each situation needs to be considered in relation to the individual, work environment and personal life elements to understand and provide appropriate support. Managers have a duty to reduce stress in the workplace and provide structures and advice that alleviate and provide opportunities for nurses to unwind regularly and relieve stress. Nurses also have a responsibility to look after their own health and ensure that they are fit for work NS
References Cox T, Randall R, Griffiths A (2002) Interventions to Control Stress at Work in Hospital Staff. The Stationery Office, Norwich. Firth-Cozens J, Cornwell J (2009) The Point of Care. Enabling Compassionate Care in Acute Hospital Settings. The King’s Fund, London. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary. tinyurl.com/bkgyem7 (Last accessed: December 17 2013.) Health and Safety Executive (2013a) Work Related Stress – Together We Can Tackle It. www.hse.gov.uk/stress/ index.htm (Last accessed: December 17 2013.)
Health and Safety Executive (2013b) Stress and Psychological Disorders in Great Britain 2013. www.hse.gov.uk/statistics/causdis/ stress/stress.pdf (Last accessed: December 17 2013.) Health and Safety Executive (2013c) What is Stress? tinyurl. com/3yt843v (Last accessed: December 17 2013.) Health and Safety Executive (2013d) What are the Management Standards. www.hse.gov.uk/ stress/standards/index.htm (Last accessed: December 17 2013.) Jennings B (2008) Work stress and burnout among nurses: role of the work environment and working conditions. In Hughes R (Ed) Patient Safety and Quality:
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An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality, Rockville MD, 1-22. Lazarus RS, Folkman S (1984) Stress, Appraisal, and Coping. Springer, New York NY. Marieb E (2010) Essentials of Human Anatomy and Physiology. Tenth edition. Benjamin Cummings, San Francisco CA. Marine A, Ruotsalainen J, Serra C, Verbeek J (2009) Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews. Issue 4, CD002892. Rothschild B (2006) Help for the Helper: Self-Care Strategies for
Managing Burnout and Stress. WW Norton and Company, New York NY. The Press Association (2013) Two-Thirds of Nurses ‘Consider Quitting’ Due to Stress, says RCN. tinyurl.com/kkrssru (Last accessed: December 17 2013.) Wicks RJ (2010) Bounce: Living the Resilient Life. Oxford University Press, New York NY. Wright K, Sweet P, Ascott N, Chummun H, Taylor J (2011) Managing common symptoms of long-term conditions. In Meerabeau E, Wright K (Eds) Long-Term Conditions: Nursing Care and Management. Wiley-Blackwell, Chichester, 135-176.
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Nursing Standard 2014.28:37-42. Downloaded from journals.rcni.com by McMaster University on 12/10/15. For personal use only.
If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Alleviating stress in the workplace: advice for nurses Wright K (2014) Alleviating stress in the workplace: advice for nurses. Nursing Standard. 28, 20, 37-42. Date of submission: October 2 2013; date of acceptance: October 18 2013.
Abstract Stress is an inherent and arguably essential aspect of the nurse’s role, with ongoing challenges associated with providing care for patients and their families. However, the level of stress currently being experienced in health care exceeds the capacity of many nurses, resulting in ill health and burnout. This stress can undermine the care and compassion nurses are able to give, a vital concern in health care which was highlighted by the Francis inquiry. This article explores the factors that contribute to stress and the strategies that can be used to alleviate the stresses inherent in nursing.
Author Kerri Wright Honorary staff counsellor, Occupational Health and Well being, Kingston Hospital NHS Foundation Trust, Surrey. Correspondence to: [email protected]
Keywords Burnout, compassion, counselling, leadership and management, self-care, stress
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
NURSING IS A stressful job. Excess and prolonged stress can lead to distress, burnout or physical illness for the individual (Marine et al 2009). For the organisation, stress can result in staff absence, increased staff turnover and increased costs, all of which can contribute to further stress for staff (Marine et al 2009, Francis 2013). The Health and Safety Executive (HSE) (2013a), through the Management of Health and Safety at Work Regulations 1999, identified stress as a health and safety issue and requires all organisations, including the NHS, to undertake stress risk assessments for staff to identify and prevent stress-related ill health. Increased stress has been linked to a reduction in compassion and caring in health care (Firth-Cozens and Cornwell 2009) and has become a major concern following the Francis (2013) inquiry. Nurses are more likely than other healthcare professionals to experience ill health because of stress, with 2,730 cases of sick leave because of work-related stress in 2011/12 per 100,000 nurses (HSE 2013b). Workers in the UK experiencing work-related stress in 2011/12, took 24 days off work on average (HSE 2013b). In a survey of 10,000 nurses by the Royal College of Nursing (RCN), 62% of nurses questioned reported that they had considered leaving the profession because of stress (The Press Association 2013).
Defining stress Stress is a response to perceived threat activated by the sympathetic nervous system (Wright et al 2011). The purpose of stress is to prepare the body for physical action. Therefore, heart rate increases, and blood flow increases to core organs and muscles, and decreases to peripheral or
© NURSING STANDARD / RCN PUBLISHING Nursing Standard 2014.28:37-42.
january 15 :: vol 28 no 20 :: 2014 37
Downloaded from journals.rcni.com by McMaster University on 12/10/15. For personal use only.
Art & science occupational health non-essential areas, for example the gut. This results in increased blood pressure, rapid and shallow breathing, and tension in the muscles; the body is in ‘fight or flight’ mode, ready for the danger sensed (Marieb 2010). Many chemicals are also released into the bloodstream as part of the stress response, in particular adrenaline (epinephrine) and corticosteroids (Rothschild 2006), to help prepare the body for action. When the body is required to act and respond to the threat as it has been designed to do, for example dealing with a clinical emergency or implementing care at a fast pace, the chemicals are discharged from the body, tension in the muscles relaxes, and heart rate and blood pressure return slowly to normal levels. Adverse effects on health occur when action cannot be taken to fight or flee the perceived threat and/or the threat is prolonged and enduring (Wicks 2010) (Box 1).
BOX 1 Levels of health problem that can occur when stress is prolonged or cannot be avoided Level 1 Signs and symptoms are relatively mild, short in duration and occur occasionally: Feeling mentally fatigued at the end of the day. Feeling unappreciated, frustrated, bored, tense or angry as a result of contact(s) with family, colleagues, supervisors, superiors, assistants or others. Experiencing physical symptoms, for example headache, backache and upset stomach. Pace of daily activities or requirements of present tasks seem greater than personal or professional resources available. Tasks required on the job are repetitive, beyond ability or require intensity on a continuous basis. Level 2 Signs and symptoms have become more persistent, last longer and are more difficult to eliminate: Idealism and enthusiasm about one’s occupation or profession is waning; disillusionment about work arises on a regular basis. Experiencing a general loss of interest in self for a period of one month or longer. Pervasive feelings of boredom, stagnation, apathy and frustration. Being ruled by schedule; not attuned to people or patients and colleagues, and viewing them impersonally and without consideration. Losing criteria with which to judge the effectiveness of work. Inability to be refreshed by other elements in one’s life, such as reading a book. A loss of interest in professional developments – new evidence, ideas and innovations for health care, for example. Intermittent but lengthy periods (lasting one week or more) of irritation, depression and stress that do not seem to be relieved even with effort to correct apparent causes. Level 3 Signs and symptoms have become chronic and a physical illness has developed, for example hypertension, colitis, depression and/or anxiety. (Wicks 2010)
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Stress occurs when perceived demands or pressures exceed current resources and potentially threaten wellbeing (Lazarus and Folkman 1984, HSE 2013c). In health care, there are challenges that could be perceived as threatening the wellbeing of nurses. For example, reduced services, focus on performance targets, staff shortages and increases in individual workloads contribute to the challenges nurses experience regularly (Francis 2013). The response to and perception of these challenges in health care are different for each nurse. The body responds to what is individually perceived to be threatening wellbeing. This involves beliefs, thoughts and feelings about the situation. The situation in reality, may not seem threatening to the individual or to those observing from the outside, nor will the situation affect everyone in the same way. To understand how these challenging situations come to be perceived as threatening to the wellbeing of individual nurses, it is important to consider the demands of the work environment as causes of stress, the individual and how he or she is coping, as well as the complex interplay between the individual and his or her work environment and how this contributes to stress.
Factors causing stress Stress is caused when the demands placed on an individual exceed the resources he or she has at that time (Cox et al 2002, HSE 2013c). The demands on nurses derive not only from work, but include responsibilities and challenges in their personal lives (Jennings 2008). Although nurses are often told to leave their personal lives at home, the reality is that personal lives and sometimes family commitments affect work, for example an ill relative or childcare difficulties. Similarly, a person’s resources can become drained by demands and pressures at work and at home or a combination of both. A personal crisis can damage resources, resulting in reduced reserves for work. In the same way, work can drain resources, resulting in reduced reserves for managing personal lives. In addition, an individual’s resources will affect the number and type of demands that can be managed. This involves personal experiences and strategies for dealing with situations as well as feelings at a particular moment. At times of tiredness or distress, resources will be reduced. At other times, when the individual is refreshed and feeling confident, resources are greater. Resources are thus individual and can fluctuate. It is important, therefore, to consider all elements of a nurse’s life when assessing the demands on his or her resources and how these can be maximised to alleviate stress.
© NURSING STANDARD / RCN PUBLISHING
Nursing Standard 2014.28:37-42. Downloaded from journals.rcni.com by McMaster University on 12/10/15. For personal use only.
When stress occurs in several areas, then it is likely that stress will be greater. Figure 1 illustrates that stress not only occurs in the overlapping areas of individual, personal life and work environment, but that each area can have an effect on available resources and whether resources can meet demand. To alleviate stress, nurses and managers need to consider how the demands placed on nurses can be reduced and how the resources to manage these demands can be increased. This requires nurses to consider the demands of personal lives, work and personal pressure, for example perfectionism or the need to feel valued. Nurses need to consider how resources can be increased from individual, personal and work perspectives. One of the recurring themes from research on the causes of stress experienced by healthcare professionals is whether nurses feel empowered in their work. Feeling disempowered appears to increase the perception of stress (Jennings 2008) and when nurses are given more autonomy they tend to feel less stressed. A study by the RCN and Unison commissioned by the HSE found that stress was not only experienced when the demands on nurses exceeded their resources, but was determined by the nurse’s perception of the demands and whether he or she felt able to cope (Cox et al 2002). Therefore, stress can be alleviated by reducing the demands or by increasing resources to cope with the demands, and by considering nurses’ beliefs about the situation and increasing the perceived control they have over what is happening to them.
Managing stress Stress can be alleviated by addressing the individual, work and personal life elements of a nurse’s life that contribute to stress, and examining how these elements interact and contribute to stress.
Individual element of stress
An individual’s ability to manage the demands placed on him or herself increases if he or she feels they have sufficient resources to meet these demands. For nurses, these resources include physical, emotional and mental capacity alongside clinical knowledge and skills. There is a complex interplay between these areas so that a reduction in one, for example feeling distressed, can impair the nurse’s ability to think clearly, make him or her feel physically drained and tired, and can affect his or her clinical performance. Similarly, if a nurse does not feel competent clinically and cannot meet the demands placed on him or her, the nurse can feel worthless, which can contribute to a pattern of negative thinking. Therefore, alleviating and managing stress requires the nurse to consider
FIGURE 1 Three interacting elements of stress
Individual
Work environment
Personal life
how situations at work make him or her feel, his or her thoughts about the situation and his or her behaviour, as well as paying attention to his or her physical health (Figure 2). Exploring these areas and taking steps to increase physical health or challenge thoughts about a situation, increases resources as a nurse will feel more in control of what is happening and more able to cope. The situation may not necessarily change, but the way the nurse thinks about it can, for example the nurse may be clearer about why the situation is causing him or her so much concern, what he or she can do to improve the situation, and what he or she may need to accept. Stress is exacerbated by feelings of being trapped and having no control over the situation (Jennings 2008, Wicks 2010). Part of alleviating stress is challenging this and gaining some control over the situation. Advice for managing stress is provided in Box 2. Counselling can be useful to help individuals become more aware of habitual patterns of thinking and to learn different strategies and techniques to help manage thoughts and feelings in situations (Marine et al 2009).
Work environment element of stress
The work environment and the structures in place to support staff are important in alleviating stress (Cox et al 2002, Jennings 2008, Firth-Cozens and Cornwell 2009). Challenges associated with providing complex care with decreasing resources are common in health care today. Healthcare settings can be under-staffed or can have high
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Art & science occupational health staff turnover, which has a negative effect on the experience and expertise available for patient care in the clinical area (Marine et al 2009, Francis 2013). The increase in work-related pressures inevitably leads to stress or other ill health causing sickness and absences, which leads to further understaffing and stress for the remaining staff. Healthcare work is demanding and workplaces need to look at how individuals can be given the resources to manage better these demands and what the workplace can do to minimise the demands being placed on nurses. The HSE (2013d) defined six management standards relating to the work environment that are the primary sources of stress at work and which need to be considered in any assessment of stress in the workplace. These standards are listed in Box 3.
FIGURE 2
v
Cycle of negative thinking Situation You cannot complete your workload
Thoughts I’m not doing a good job; I can’t do this job; I’m not good enough
Physical effects Tiredness, headaches, dizziness, poor concentration
Feelings On edge, scared, irritable, despairing, tearful
Behaviour Come into work early and stay late, take work home
BOX 2 Advice on managing stress Get enough sleep. Eat regular and nourishing meals and snacks. Incorporate exercise into the weekly routine. Take regular breaks at work. Make time to relax away from work. Problem solve and take action. Consider accepting that which cannot be controlled. Appreciate the individual and what the individual is doing. Focus on what gives meaning in work. Separate the personal from work and have interests and roles outside work that give life meaning.
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One of the main factors that alleviates stress in health care is the quality of leadership and management support given to staff (Firth-Cozens and Cornwell 2009, Francis 2013). Good management can ensure that structures are in place to support staff and that staff have the resources they need to perform their role (Jennings 2008). The study by the RCN and Unison identified eight areas of good practice that can help to alleviate stress in the workplace (Cox et al 2002) (Box 4). The examples of good practice help staff to focus on reducing demands, and resourcing and supporting staff and teams to better manage these demands. This involves managers having a genuine understanding of the work situation or a desire to hear and act on feedback from staff. This does not mean solely reducing the workload, but offering support, checking back with staff periodically and listening to the difficulties nurses are having at that time.
Personal life element of stress
Nurses should not let their personal lives affect their work, but the reality is that one’s personal life does affect work. When nurses are energised and confident, work will benefit. Similarly, when personal issues are causing distress and affecting sleep, for example, energy and resources available for work are limited. When nurses are stressed in their personal lives, they are more at risk of stress and ill health at work. It is important to accept that personal life will affect work and that a nurse may gain support during a personal crisis by informing his or her manager, consulting occupational health services and exploring psychological support through counselling.
BOX 3 Management standards for work-related stress Demands – this includes issues such as workload, work patterns and the work environment. Control – how much influence the person has in the way he or she works. Support – this includes encouragement, sponsorship and resources provided by the organisation, line management and colleagues. Relationships – this includes promoting positive working to avoid conflict and dealing with unacceptable behaviour. Role – whether people understand their role in the organisation and whether the organisation ensures that they do not have conflicting roles. Change – how change (large or small) is managed and communicated in the organisation. (Health and Safety Executive 2013d)
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For many, working life involves multiple roles and trying to manage these to ensure that expectations are met. It is important that managers appreciate the competing and conflicting roles that nurses have. Stress can be alleviated by allowing dialogue about work times and shift patterns where possible. For example, managers need to weigh up the benefit of reducing stress by allowing a nurse to finish half an hour earlier to take his or her child to a doctor’s appointment against the distress caused by denying this and affirming that the times when the nurse stayed late and worked hard have not been recognised. In addition, nurses have a responsibility to look after their health as best they can. This means managing personal commitments and balancing these with work demands. Maintaining a good work-life balance may require the nurse and his or her manager to negotiate this together.
Warning signs Nurses are accustomed to working under pressure and experience stress as an everyday feature of their work. Unless this stress is relieved in some way (Box 5), the effects on the body of being on high alert for long periods can have long-term consequences for health such as hypertension or depression. It is important, therefore, to integrate time into the daily schedule to de-stress. Stress is the body’s response to a perceived threat and prepares the body for action, physically and cognitively. The body is, therefore, ‘wound-up’, ready for physical action, and thoughts are alert and focused on the perceived stressor. Stress can be relieved via physical activity or talking through the events of the day (debriefing) to make sense of them. It is also important to consider relaxation techniques such as mindfulness practice, meditation, yoga or tai chi (Marine et al 2009). If the body and mind are not given an opportunity to discharge the energy, this will stay in the body and make it difficult for the individual to relax physically and mentally. Over a long period, this stress can start to have physical effects, causing hypertension or ulcers, and psychological effects, such as anxiety or depression. The long-term effects of stress can be invisible until quite a late stage, unless steps are taken to be more aware of responses to situations and to acknowledge that the shift or situation was stressful. Once an individual becomes physically and/or psychologically unwell through stress, it can take a long time to recover. Nurses should be taught – whether during pre-registration training, or later by occupational health staff or their manager – to recognise the early warning signs and take steps
BOX 4 Eight areas of good practice that can help to alleviate stress in the workplace 1. I ntroduce a forum for community information and to discuss and solve problems, for example team meetings or problem-solving workshops. 2. Make opportunities available for staff to design work that is interesting and stimulating, and allow staff a degree of control over how they do their work. If work is not interesting, managers should ensure job rotation so that staff experience some variety. 3. Ensure continuity of care so that staff can take responsibility for the care they provide and can see improvements in their patients. Direct care staff are known to derive satisfaction from seeing their work making a difference to people. 4. Use in-house training and systems to consolidate and disseminate expertise. Services should use the knowledge and expertise of their staff as a resource for training others, for example regular training sessions or specific roles such as nurse practitioners. 5. Help staff to develop by undertaking effective performance appraisal. 6. Be flexible about working hours where appropriate, for example reasonable request systems could be put in place to help manage the effect of work on home and social life. Open dialogue between those organising working hours and staff is crucial for these systems to work. 7. Promote cohesive and well managed teams. Management practices that actively discourage isolated working enhance the team environment. Working relationships are important to staff, and continuity of staffing is important for staff wellbeing. 8. Manage the work environment effectively, for example ensure that equipment is up to date and well maintained, and systems are in place to ensure condition and availability are monitored. (Cox et al 2002)
BOX 5 Ideas for relieving stress Mind: Introduce a debrief time with colleagues at the end of work where successes and frustrations of the day can be shared. Write a brief reflective journal after each shift with a focus on what went well, what could be improved and what could be done next time. Plan what needs to be done and write it in the journal. Create an escape from thoughts about work, for example watch television, read a book or have coffee with friends. Practise mindfulness through yoga or meditation to help focus on the present and control thinking around work. Have a period of protected ‘me time’ each day. This can be quietly listening to some music, sitting with a cup of tea and doing a puzzle or taking a warm bath. Find a time that fits into the routine and becomes a regular period for the mind to disengage from work. Body: Do some form of physical exercise regularly. The more vigorous the better, so that frustrations can be worked off during the activity. Punch some pillows or use a stick or baseball bat to hit them with. Find somewhere secluded and scream. Put music on full volume and sing or dance along as loudly and energetically as possible. Complete something tangible at home to give a sense of achievement, for example bake a cake, cook a meal, clean the bathroom or vacuum the floor. The physical exertion, and the focus on the task and the end product will help to channel frustrations and relieve stress.
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Art & science occupational health to prevent further deterioration in health. Once a person becomes aware of how the body and mind react to work-related stress, then he or she may be more motivated to take steps to look after him or herself and relieve the stress every day. Nurses should include activities that enable the body to relieve some of the stress in their daily routine.
Conclusion Stress is a normal and vital part of a nurse’s working life. Prolonged stress or work in situations where nurses feel trapped can cause levels of stress that can have a long-lasting effect on health. Stress is caused by an imbalance between the demands placed on an individual and the resources he or
she has available to cope with these demands. The demands and resources available to cope are affected by the individual’s skills, thoughts and beliefs about him or herself and work, the work environment, support structures available, and his or her personal life. Stress affects people in different ways and each situation needs to be considered in relation to the individual, work environment and personal life elements to understand and provide appropriate support. Managers have a duty to reduce stress in the workplace and provide structures and advice that alleviate and provide opportunities for nurses to unwind regularly and relieve stress. Nurses also have a responsibility to look after their own health and ensure that they are fit for work NS
References Cox T, Randall R, Griffiths A (2002) Interventions to Control Stress at Work in Hospital Staff. The Stationery Office, Norwich. Firth-Cozens J, Cornwell J (2009) The Point of Care. Enabling Compassionate Care in Acute Hospital Settings. The King’s Fund, London. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary. tinyurl.com/bkgyem7 (Last accessed: December 17 2013.) Health and Safety Executive (2013a) Work Related Stress – Together We Can Tackle It. www.hse.gov.uk/stress/ index.htm (Last accessed: December 17 2013.)
Health and Safety Executive (2013b) Stress and Psychological Disorders in Great Britain 2013. www.hse.gov.uk/statistics/causdis/ stress/stress.pdf (Last accessed: December 17 2013.) Health and Safety Executive (2013c) What is Stress? tinyurl. com/3yt843v (Last accessed: December 17 2013.) Health and Safety Executive (2013d) What are the Management Standards. www.hse.gov.uk/ stress/standards/index.htm (Last accessed: December 17 2013.) Jennings B (2008) Work stress and burnout among nurses: role of the work environment and working conditions. In Hughes R (Ed) Patient Safety and Quality:
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An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality, Rockville MD, 1-22. Lazarus RS, Folkman S (1984) Stress, Appraisal, and Coping. Springer, New York NY. Marieb E (2010) Essentials of Human Anatomy and Physiology. Tenth edition. Benjamin Cummings, San Francisco CA. Marine A, Ruotsalainen J, Serra C, Verbeek J (2009) Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews. Issue 4, CD002892. Rothschild B (2006) Help for the Helper: Self-Care Strategies for
Managing Burnout and Stress. WW Norton and Company, New York NY. The Press Association (2013) Two-Thirds of Nurses ‘Consider Quitting’ Due to Stress, says RCN. tinyurl.com/kkrssru (Last accessed: December 17 2013.) Wicks RJ (2010) Bounce: Living the Resilient Life. Oxford University Press, New York NY. Wright K, Sweet P, Ascott N, Chummun H, Taylor J (2011) Managing common symptoms of long-term conditions. In Meerabeau E, Wright K (Eds) Long-Term Conditions: Nursing Care and Management. Wiley-Blackwell, Chichester, 135-176.
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